AB0967 REFRACTORY ACHILLES ENTHESITIS SUCESSFULY TRAETED BY IXEKIZUMAB LOCAL INJECTION
Authors: A. Abogamal
Journal: Annals of the Rheumatic Diseases (2023)

<h3>Background</h3> Axial spondyloarthropathy (axSpA) is a chronic autoimmune inflammatory disease that involves the axial skeleton with inflammatory back pain as the most common presenting symptom. [1] Apart from the axial joints, enthesis are frequently involved in spondyloarthopathy (SPA) and clinical enthesitis reported to affects 10% – 60% of SPA patients. Enthesitis usually involves the lower limb and heel pain represents a significant clinical challenge due to frequent presence of Achilles enthesitis (AE), retrocalcaneal bursitis (RB) and plantar fasciitis, plus a treatment challenge in refractory cases that usually not controlled by conventional DMARDs and fails to respond to biological treatment [2-4]. <h3>Objectives</h3> To describe a successful management of refractory case of AE after US guided Ixekizumab injection to the RB. <h3>Methods</h3> Male 42 y old known case of axSpA for 22 y with +ve HLAB27 and bilateral AE. initially treated with salazopyrine, and NSAIIDs with no response and treatment escalated to Infleximab with secondary failure after 6 months, switched etanercept injection with primary failure. Patinet achived god clinical responce on adalimumab which was maintained up to 7y, followed by secondry faliure due to antidrug antibodies, resolved by addding Methotrexate. July 2019, developed hepatotoxicity due to methotrexate with discontinuation. December 2019, patient switched to Ixekizumab with successful control of his disease. Apart from the course of axial disease, January 2019 his heel pain becomes refractory to treatment VAS 8 with US assessment shows AE, RB, and tendinitis with positive Doppler signals. pain was partially responding to the added physiotherapy and NSAIDs with VAS fluctuating between 5 and 6 on both sides. February 2020, after initiation of Ixekizumab AE resoluted on the right-side VAS 0, while the left side still symptomatic VAS 6. US of the left Achilles insertion shows hypoechogenety of the tendon, distended RB, positive Doppler signals involving the bursa and extending to the tendon body. Figure 1 March 2020, an US guided injection with Triamcinolone acetate 20mg infiltrated to the RB failed to control pain with partial response for two weeks. July 2020, an US guided injection of the RB with Ixekizumab 80mg arranged two weeks after application of the systemic Ixekizumab. <h3>Results</h3> Three months after Ixekizumab local injection, heel pain drops to VAS 0, with radiological improvement in US; resolution of the Doppler signals and the RB. On follow up from July 2020 - January 2022; Resolution of heel pain, AE and RB persists since the application of Ixekizumab, with normalized Doppler and RB. Figure 1 <h3>Conclusion</h3> US Guided local application of Ixekizumab successfully help to resolve pain and inflammation in a refractory case of AE. <h3>References</h3> [1]McGonagle D, Khan MA, Marzo-Ortega H, O'Connor P, Gibbon W, Emery P. Enthesitis in spondyloar thropathy. Curr Opin Rheumatol1999;11:244–50. [2]Olivieri I, Barozzi L, Padula A. Enthesiopathy: clinical manifestations, imaging and treatment. Baillieres Clin Rheumatol 1998;12:665–81. [3]Amor B, Dougados M, Khan MA. Management of refractory ankylosing spondylitis and related spondyloarthropathies. Rheum Dis Clin North Am 1995; 21: 117–28. [4]Brandt J, Haibel H, Cornely D, Golder W, Gonzalez J, Reddig J, et al. Successful treatment of active ankylosing spondylitis with the anti–tumor necrosis factor α monoclonal antibody infliximab. Arthritis Rheum 2000; 43: 1346–52. <h3>Acknowledgements:</h3> NIL. <h3>Disclosure of Interests</h3> Ahmed Abogamal Speakers bureau: Pfizer, Novartis, Lilly, Abbvie, Novartis, Astra-Zeneca, Amgen, Janssen.